Background: Costal fracture surgical is still a debate, therefore we shall select between early and delay surgical management. Case Report: We are reporting two cases of post road traffic clash delay ribs fractures os...Background: Costal fracture surgical is still a debate, therefore we shall select between early and delay surgical management. Case Report: We are reporting two cases of post road traffic clash delay ribs fractures osteosynthesis involving a 63-year-old man with multistage fractures on the left and pulmonary pinning of one of the costal arches, complicated by a homolateral haemothorax and a 41-year-old man with a bilateral flail chest. Conclusion: The simple postoperative course and the immediate postoperative improvement in the patient’s clinical respiratory condition enabled us to discuss the time frame for management, in this case the indication for early or later surgery.展开更多
BACKGROUND Post-traumatic blunt pericardial injury is a rare condition with only a few reported cases which were generally diagnosed during initial examinations upon admission.However,pericardial injuries not bad enou...BACKGROUND Post-traumatic blunt pericardial injury is a rare condition with only a few reported cases which were generally diagnosed during initial examinations upon admission.However,pericardial injuries not bad enough to dislocate the heart may only cause intermittent electrocardiogram(ECG)changes or be asymptomatic.CASE SUMMARY In this case,we report a blunt pericardial injury undetected on preoperative transthoracic echocardiography and chest computed tomography.We misjudged intermittent ECG changes and blood pressure fluctuations as minor symptoms resulting from cardiac contusion and did not provide intensive treatment.The pericardial injury was found incidentally during surgical stabilization of rib fractures and was successfully repaired.CONCLUSION Post-traumatic blunt pericardial ruptures should be considered in patients with blunt chest trauma showing abnormal vital signs and ECG changes.展开更多
Background: Traumatic flail chest is a serious injury that can impair ventilation and affect patient outcome. Thoracic epidural analgesia is the gold standard to provide adequate analgesia in flail chest, however, it ...Background: Traumatic flail chest is a serious injury that can impair ventilation and affect patient outcome. Thoracic epidural analgesia is the gold standard to provide adequate analgesia in flail chest, however, it may be unavailable in some patients due to coagulopathy, failure or difficult insertion. We compared between parenteral dexmedetomidine and thoracic epidural block with plain local anesthetic in flail chest cases. Patients and methods: fifty eight trauma patients with flail chest randomly allocated into either Group E (n = 29): epidural group, patients received mid-thoracic epidural analgesia using 6 ml mixture of 0.125% bupivacaine and 2 μg/ml fentanyl, which followed by continuous infusion of 6 ml/hour;Group D (n = 29): dexmedetomidine group, patients received loading dose of dexmedetomidine 1 μg/kg over 30 min, after a continuous infusion at a rate of 0.5 μg/kg/hr. The primary outcomes were to assess the effect of analgesic type on ventilation (PaO2/FIO2 ratio, PaCO2). The secondary outcomes were to compare analgesic effect, hemodynamics, the need for ventilation and ICU stay. Result: PaO2/FIO2 ratio was significantly higher in epidural group and PaCO2 was significantly lower in epidural group (p value < 0.05). The incidence of mechanical ventilation was significantly lower in epidural group than in dexmedetomidine group (6 patients group versus 13 patients, p value < 0.04). Mean arterial blood pressure was significantly lower in dexmedetomidine group than in epidural group (94.3 ± 6.84 mmHg versus 102 ± 5.72 mmHg, p value < 0.001). Moreover, heart rate was significantly lower in dexmedetomidine group than epidural group (89.97 ± 6.22 bpm versus 96.07 ± 9.3 bpm, p value = 0.004). VAS was significantly lower in epidural group (p value < 0.001). Throughout different measuring points, RAMSAY score was significantly higher in dexmedetomidine group. Conclusion: Epidural analgesia is more effective than parenteral dexmedetomidine in flail chest, but dexmedetomidine can represent a good alternative if epidural is not possible.展开更多
BACKGROUND Many patients have inadequate long-term analgesia,respiratory distress,and hypoxemia due to a long-standing substantial smoking history or the presence of primary pulmonary diseases;analgesic treatment is n...BACKGROUND Many patients have inadequate long-term analgesia,respiratory distress,and hypoxemia due to a long-standing substantial smoking history or the presence of primary pulmonary diseases;analgesic treatment is not valid in these patients.Even if the imaging findings of rib fractures are relatively mild,rib fractures may cause severe position limitation,respiratory distress,and hypoxemia.AIM To investigate the curative effect of surgical treatment for patients with severe non-flail chest rib fractures.METHODS A total of 78 patients from our hospital with severe noncontinuous thoracic rib fractures from September 2016 to September 2018 were enrolled in our study.Thirty-nine patients underwent surgical treatment,and 39 underwent conservative treatment.The surgical treatment group received surgery performed with titanium plates,and the screws were inserted with open reduction and internal fixation.The conservative treatment group received analgesia and symptomatic treatment.The pain scores at 72 h,1 wk,2 wk,4 wk,6 wk,3 mo,and 6 mo were compared,and the SF-36 quality of life scores were compared atthe 3rd and 6th months.RESULTS Pain relief in the surgical group was significantly better than that in the conservative group at each time point(72 h,1 wk,2 wk,4 wk,6 wk,3 mo,and 6 mo after surgery,P<0.001).The SF-36 scores were significantly higher in the surgical group than in the conservative group at 1 mo and 6 mo(P<0.05).CONCLUSION Patients with severe non-flail chest rib fractures have a better quality of life following surgical treatment than following conservative treatment,and surgical treatment is also useful for relieving pain.We should pay more attention to the physiological functions and clinical manifestations of patients with severe rib fractures.In patients with non-flail chest rib fractures,surgical treatment is feasible and effective.展开更多
BACKGROUND Multiple myeloma is a malignant neoplasm of the bone marrow characterized by neoplastic proliferation of monoclonal plasma cells with a high relationship with destructive bone disease. We present a case of ...BACKGROUND Multiple myeloma is a malignant neoplasm of the bone marrow characterized by neoplastic proliferation of monoclonal plasma cells with a high relationship with destructive bone disease. We present a case of a patient diagnosed with multiple myeloma and sternal fracture in association with multiple bilateral rib fractures and thoracic kyphosis, who developed a severe acute respiratory failure, thus complicating the initial presentation of multiple myeloma. We discuss the therapeutic implications of this uncommon presentation. CASE SUMMARY A 56-year-old man presented to Hematological Department after he had been experiencing worsening back pain over the last five months, with easy fatigability and progressive weight loss. He had no history of previous trauma. The chemical blood tests were compatible with a diagnosis of multiple myeloma. A radiographic bone survey of all major bones revealed, in addition to multiple bilateral rib fractures, a sternal fracture and compression fracture at T9, T10, T11 and L1 vertebrae. Subcutaneous fat biopsy was positive for amyloid. We started treatment with bortezomib and dexamethasone. After 24 h of treatment, he presented dyspnea secondary to flail chest. He required urgent intubation and ventilatory support being transferred to intensive care unit for further management. The patient remained connected to mechanical ventilation (positive pressure) as treatment which stabilized the thorax. A second cycle of bortezomib plus dexamethasone was started and analgesia was optimized. The condition of the patient improved, as evidenced by callus formation on successive computed tomography scans. The patient was taken off the ventilator one month later, and he was extubated successfully, being able to breathe unaided without paradoxical motion. CONCLUSION This case highlights the importance of combination between bortezomib and dexamethasone to induce remission of multiple myeloma and the initiation of positive airway pressure with mechanical ventilation to stabilize chest wall to solve the respiratory failure. This combined approach allowed to obtain a quick and complete resolution of the clinical situation.展开更多
A flail chest is characterized by four or more rib fractures unilaterally or at more than two sites. The current article reports a 10-year-old case of a flail chest due to a simple fall from a chair while at breakfast...A flail chest is characterized by four or more rib fractures unilaterally or at more than two sites. The current article reports a 10-year-old case of a flail chest due to a simple fall from a chair while at breakfast. This pediatric case is presented because of its rare occurrence with a successful external tamponade application. Pneumothorax and tension pneumothorax associated with simple falls should be considered in pediatric patients. In the current case, blunt chest trauma-associated bilateral multiple rib fractures and a flail chest were present. The chest wall was destabilized and respiratory functions were compromised. Early stabilization with tube thoracostomy and external tamponade were achieved in the emergency setting. Intubation was not required after these procedures.展开更多
Flail chest occur after blunt trauma to the thorax. Most often treatment of flail chest is conservative with analgesia and respiratory support, if needed. New plate systems and surgical approaches have improved outcom...Flail chest occur after blunt trauma to the thorax. Most often treatment of flail chest is conservative with analgesia and respiratory support, if needed. New plate systems and surgical approaches have improved outcomes after surgery. Surgical treatment of flail chest is associated with a reduced risk of severe pneumonia, shorter time with mechanical ventilation and a reduced length of stay in the Intensive Care Unit (ICU) compared to conservative treatment. However, currently approximately 1% of patients with flail chest undergo surgery. We are presenting two cases of flail chest treated surgically by fixating the most dislocated posterior fractures. One patient avoided mechanical ventilation, and the other patient was quickly weaned from respirator after surgery. We found that surgical stabilization of posterior fractures in patients with flail chest is a safe method with a high possibility of positive outcomes for the patients. Surgical stabilization of flail chest is indicated in patients with consistent pain (case 1) and increased risk of pneumonia, respiratory failure or prolonged mechanical ventilation (case 2). Furthermore, it was possible to achieve stable thorax wall by only fixating the most dislocated posterior fractures in the flail segment.展开更多
Surgical stabilization of the flail chest is challenging and has no established guidelines.Chest wall integrity and stability are the main factors that ensure the protection of intrathoracic organs and an adequate res...Surgical stabilization of the flail chest is challenging and has no established guidelines.Chest wall integrity and stability are the main factors that ensure the protection of intrathoracic organs and an adequate respiratory function.Here,we report a novel chest wall reconstruction technique in a 45-year-old man with a traumatic left flail chest and open pneumothorax diagnosed both clinically and radiographically.Rib approximation and chest wall reconstruction was done using intercostal figure-of-eight suture and polypropylene mesh with vascularized musculofascial flap.The patient improved gradually and was discharged after three weeks of total hospital stay.He returned to regular working after a month with no evidence of respiratory distress or paradoxical chest movement.Follow-up visit at one year revealed no lung hernia or paradoxical chest movement.This is a novel,feasible and cost-effective modification of chest wall reconstruction that can be adopted for thoracic wall repair in case of open flail chest,which needs emergency surgical interventions even in resource constraint settings.展开更多
文摘Background: Costal fracture surgical is still a debate, therefore we shall select between early and delay surgical management. Case Report: We are reporting two cases of post road traffic clash delay ribs fractures osteosynthesis involving a 63-year-old man with multistage fractures on the left and pulmonary pinning of one of the costal arches, complicated by a homolateral haemothorax and a 41-year-old man with a bilateral flail chest. Conclusion: The simple postoperative course and the immediate postoperative improvement in the patient’s clinical respiratory condition enabled us to discuss the time frame for management, in this case the indication for early or later surgery.
文摘BACKGROUND Post-traumatic blunt pericardial injury is a rare condition with only a few reported cases which were generally diagnosed during initial examinations upon admission.However,pericardial injuries not bad enough to dislocate the heart may only cause intermittent electrocardiogram(ECG)changes or be asymptomatic.CASE SUMMARY In this case,we report a blunt pericardial injury undetected on preoperative transthoracic echocardiography and chest computed tomography.We misjudged intermittent ECG changes and blood pressure fluctuations as minor symptoms resulting from cardiac contusion and did not provide intensive treatment.The pericardial injury was found incidentally during surgical stabilization of rib fractures and was successfully repaired.CONCLUSION Post-traumatic blunt pericardial ruptures should be considered in patients with blunt chest trauma showing abnormal vital signs and ECG changes.
文摘Background: Traumatic flail chest is a serious injury that can impair ventilation and affect patient outcome. Thoracic epidural analgesia is the gold standard to provide adequate analgesia in flail chest, however, it may be unavailable in some patients due to coagulopathy, failure or difficult insertion. We compared between parenteral dexmedetomidine and thoracic epidural block with plain local anesthetic in flail chest cases. Patients and methods: fifty eight trauma patients with flail chest randomly allocated into either Group E (n = 29): epidural group, patients received mid-thoracic epidural analgesia using 6 ml mixture of 0.125% bupivacaine and 2 μg/ml fentanyl, which followed by continuous infusion of 6 ml/hour;Group D (n = 29): dexmedetomidine group, patients received loading dose of dexmedetomidine 1 μg/kg over 30 min, after a continuous infusion at a rate of 0.5 μg/kg/hr. The primary outcomes were to assess the effect of analgesic type on ventilation (PaO2/FIO2 ratio, PaCO2). The secondary outcomes were to compare analgesic effect, hemodynamics, the need for ventilation and ICU stay. Result: PaO2/FIO2 ratio was significantly higher in epidural group and PaCO2 was significantly lower in epidural group (p value < 0.05). The incidence of mechanical ventilation was significantly lower in epidural group than in dexmedetomidine group (6 patients group versus 13 patients, p value < 0.04). Mean arterial blood pressure was significantly lower in dexmedetomidine group than in epidural group (94.3 ± 6.84 mmHg versus 102 ± 5.72 mmHg, p value < 0.001). Moreover, heart rate was significantly lower in dexmedetomidine group than epidural group (89.97 ± 6.22 bpm versus 96.07 ± 9.3 bpm, p value = 0.004). VAS was significantly lower in epidural group (p value < 0.001). Throughout different measuring points, RAMSAY score was significantly higher in dexmedetomidine group. Conclusion: Epidural analgesia is more effective than parenteral dexmedetomidine in flail chest, but dexmedetomidine can represent a good alternative if epidural is not possible.
文摘BACKGROUND Many patients have inadequate long-term analgesia,respiratory distress,and hypoxemia due to a long-standing substantial smoking history or the presence of primary pulmonary diseases;analgesic treatment is not valid in these patients.Even if the imaging findings of rib fractures are relatively mild,rib fractures may cause severe position limitation,respiratory distress,and hypoxemia.AIM To investigate the curative effect of surgical treatment for patients with severe non-flail chest rib fractures.METHODS A total of 78 patients from our hospital with severe noncontinuous thoracic rib fractures from September 2016 to September 2018 were enrolled in our study.Thirty-nine patients underwent surgical treatment,and 39 underwent conservative treatment.The surgical treatment group received surgery performed with titanium plates,and the screws were inserted with open reduction and internal fixation.The conservative treatment group received analgesia and symptomatic treatment.The pain scores at 72 h,1 wk,2 wk,4 wk,6 wk,3 mo,and 6 mo were compared,and the SF-36 quality of life scores were compared atthe 3rd and 6th months.RESULTS Pain relief in the surgical group was significantly better than that in the conservative group at each time point(72 h,1 wk,2 wk,4 wk,6 wk,3 mo,and 6 mo after surgery,P<0.001).The SF-36 scores were significantly higher in the surgical group than in the conservative group at 1 mo and 6 mo(P<0.05).CONCLUSION Patients with severe non-flail chest rib fractures have a better quality of life following surgical treatment than following conservative treatment,and surgical treatment is also useful for relieving pain.We should pay more attention to the physiological functions and clinical manifestations of patients with severe rib fractures.In patients with non-flail chest rib fractures,surgical treatment is feasible and effective.
文摘BACKGROUND Multiple myeloma is a malignant neoplasm of the bone marrow characterized by neoplastic proliferation of monoclonal plasma cells with a high relationship with destructive bone disease. We present a case of a patient diagnosed with multiple myeloma and sternal fracture in association with multiple bilateral rib fractures and thoracic kyphosis, who developed a severe acute respiratory failure, thus complicating the initial presentation of multiple myeloma. We discuss the therapeutic implications of this uncommon presentation. CASE SUMMARY A 56-year-old man presented to Hematological Department after he had been experiencing worsening back pain over the last five months, with easy fatigability and progressive weight loss. He had no history of previous trauma. The chemical blood tests were compatible with a diagnosis of multiple myeloma. A radiographic bone survey of all major bones revealed, in addition to multiple bilateral rib fractures, a sternal fracture and compression fracture at T9, T10, T11 and L1 vertebrae. Subcutaneous fat biopsy was positive for amyloid. We started treatment with bortezomib and dexamethasone. After 24 h of treatment, he presented dyspnea secondary to flail chest. He required urgent intubation and ventilatory support being transferred to intensive care unit for further management. The patient remained connected to mechanical ventilation (positive pressure) as treatment which stabilized the thorax. A second cycle of bortezomib plus dexamethasone was started and analgesia was optimized. The condition of the patient improved, as evidenced by callus formation on successive computed tomography scans. The patient was taken off the ventilator one month later, and he was extubated successfully, being able to breathe unaided without paradoxical motion. CONCLUSION This case highlights the importance of combination between bortezomib and dexamethasone to induce remission of multiple myeloma and the initiation of positive airway pressure with mechanical ventilation to stabilize chest wall to solve the respiratory failure. This combined approach allowed to obtain a quick and complete resolution of the clinical situation.
文摘A flail chest is characterized by four or more rib fractures unilaterally or at more than two sites. The current article reports a 10-year-old case of a flail chest due to a simple fall from a chair while at breakfast. This pediatric case is presented because of its rare occurrence with a successful external tamponade application. Pneumothorax and tension pneumothorax associated with simple falls should be considered in pediatric patients. In the current case, blunt chest trauma-associated bilateral multiple rib fractures and a flail chest were present. The chest wall was destabilized and respiratory functions were compromised. Early stabilization with tube thoracostomy and external tamponade were achieved in the emergency setting. Intubation was not required after these procedures.
文摘Flail chest occur after blunt trauma to the thorax. Most often treatment of flail chest is conservative with analgesia and respiratory support, if needed. New plate systems and surgical approaches have improved outcomes after surgery. Surgical treatment of flail chest is associated with a reduced risk of severe pneumonia, shorter time with mechanical ventilation and a reduced length of stay in the Intensive Care Unit (ICU) compared to conservative treatment. However, currently approximately 1% of patients with flail chest undergo surgery. We are presenting two cases of flail chest treated surgically by fixating the most dislocated posterior fractures. One patient avoided mechanical ventilation, and the other patient was quickly weaned from respirator after surgery. We found that surgical stabilization of posterior fractures in patients with flail chest is a safe method with a high possibility of positive outcomes for the patients. Surgical stabilization of flail chest is indicated in patients with consistent pain (case 1) and increased risk of pneumonia, respiratory failure or prolonged mechanical ventilation (case 2). Furthermore, it was possible to achieve stable thorax wall by only fixating the most dislocated posterior fractures in the flail segment.
文摘Surgical stabilization of the flail chest is challenging and has no established guidelines.Chest wall integrity and stability are the main factors that ensure the protection of intrathoracic organs and an adequate respiratory function.Here,we report a novel chest wall reconstruction technique in a 45-year-old man with a traumatic left flail chest and open pneumothorax diagnosed both clinically and radiographically.Rib approximation and chest wall reconstruction was done using intercostal figure-of-eight suture and polypropylene mesh with vascularized musculofascial flap.The patient improved gradually and was discharged after three weeks of total hospital stay.He returned to regular working after a month with no evidence of respiratory distress or paradoxical chest movement.Follow-up visit at one year revealed no lung hernia or paradoxical chest movement.This is a novel,feasible and cost-effective modification of chest wall reconstruction that can be adopted for thoracic wall repair in case of open flail chest,which needs emergency surgical interventions even in resource constraint settings.
